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Waste Tire S( iey & Inspection Repor Inspection Report Number <br /> cal6ecycle State of California I 1 - 1177571 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 5 Z _ © 1 Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sah 7OG.0'VtY� OVI(\ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> al - o � <br /> Physical Address 3 l <br /> Inspection Date �7 <br /> S ko c1��t o,rl C alS 206 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> /�4 � <br /> 5 i PM ) * PM <br /> 2�� ar ` Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 3 ` (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active 0 Passenger 0 Generator Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude Q Hauler Indoor <br /> O 0 Inactive ®Truck <br /> Longitude - 0 Planned • OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) Ilk <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber r <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder W.Other �a11�� 1�lAhV � �el <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility `ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments �y 1\Y\� \ O Y\ &-C'wQ a Y\ CA_Y\r' A-V <br /> ,►v0 \' :6 Qc- at'ec'.s 0V%_CecV-I\ <br /> Inspection Form Included: 0 <br /> Comments Included: 0 — '" <br /> Business Rep's Signature _ Phone Number Inspect r s Signature Phone Number <br /> -- ---- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � � � E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />